Purpose
The purpose of the Intermediate Care accelerator project is to undertake a review of the Community Recovery Service CRS - (an integrated service of health and social care offering short term reablement and rehabilitation). This service is a significant component of Hounslow’s Intermediate Care offer (home based rehabilitation, reablement, and non-urgent based admission avoidance and discharge support). The ambition of this project is to:
- Improve the Intermediate Care offer in Hounslow so that there is good community step-up provision (preventing avoidable unplanned hospital admissions and transfers to residential care)
- Optimise pathways by focussing our CRS’ expertise on patients to whom we can make a material difference to their wellbeing and rehabilitation.
The overarching objectives of this project are to contribute to reducing avoidable hospital admissions and placements into residential care, and increasing independence among residents aged 65 plus who have been supported by the service.
The current project deliverables are:
- Two-year pilot to fund two rehab nurses in CRS – to support more complex referrals, upskill the staff team, provide medication and management support. The first nurse joined the service in October 2023 and the second joined in November 2023. KPIs are being mapped to reports so that we can start to measure the impact of this solution from the first full quarter (2023/24 Q4).
- Undertake a review of the current Community Medication Policy in 2022/23 Q4.- This will include a rehabilitative element to medication support and independence. Undergoing community trust governance in 2023/24.
- Funding has been approved for a two-year pilot with Lets Go Outside and Learn to offer a non-clinical solution to patients as a redirect, or step down from CRS. The service went live in January 2024.
- A refreshed integrated criteria for CRS was agreed in September 2023 – this will help referrers identify patients suitable for reablement and/or rehabilitation in a single criteria. This has been in use since then, and will be reviewed periodically to ensure it is achieving more appropriate flow into the service.
Next Steps
Continue to implement solutions:
1. CRS Nurses are both in post and we are monitoring outputs and outcomes against the business case. Currently CRS is working to automate KPI reporting.
2. Pilot with Lets Go Outside and Learn soft launched in January 2024, referrals being monitored and the provider is working closely with the team to identify suitable patients for stepped down support.
Earlier project delivery phases included: research and stakeholder engagement which can be evidenced via the following case studies: